Have you ever received professional massage/bodywork before?
Yes
No
How recently?
How often?
What types of bodywork do you prefer?
What kind of pressure do you prefer?
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
How do you feel today?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?
Yes
No
Explain:
List the medications you currently take (including vitamins and supplements):
Are you PREGNANT?
Yes
No
Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Gender
Address
Street Address
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referred by:
Emergency contact name
Emergency contact phone
Please enter a valid phone number.
Is this massage/bodywork medically necessary (is it for a medical condition, injury, or surgery)?
Yes
No
Do you have a physician referral/prescription
Yes
No
Are you seeking insurance reimbursement?
Yes
No
Client signature
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